Laserfiche WebLink
Waste Tire Me & Ins Inspection Repo Report Number <br /> =�o Y p <br /> State of California Il - 1143630 <br /> Cgrated asteManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey__ -_ _ _ BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TPID- - � I Inspection Type (Fill one) <br /> � <br /> Site Suffix: l Xu ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S a(\ �Ovuj 1ki n ((D-1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> P \u Ma c �I In 3 _ <br /> Physical Address l U I 1,& <br /> (A ��� b Inspection Date 3 a- I U <br /> Time In Time Out { <br /> Business Rep Title ��qq �1C (,� S O AM Q AM <br /> V <br /> GU e. Wr 4 J A PM I PM <br /> -- -- - - ----------- - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair 0-Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility LENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Datem / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments tt � ��L <br /> L'Lft4-A_tp4_ or_mrKr�c�A �5 a �[`(1 o �.� GS "C <br /> Inspection Form Included: Qi �S <br /> Comments Included: �' V <br /> Bup's Signature Phone Number Inspec s Signature hone Number <br /> -- - <br /> A <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: A M 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />